Child Abuse as an Example of Coexistence of Emotional and Physical Trauma Among Children: An Academic Overview With Altmetric Perspective

Introduction: Child abuse combines emotional, physical, sexual, and neglect aspects of violence, thus diversifying the trauma for a child. Publications about child abuse had been discussed in academia for long years and evaluated by bibliometric analysis, frequently. This study aims to evaluate the most discussed/disseminated scientific publications about child abuse in electronic media such as social media accounts, blogs, podcasts, and media news sites using a new analysis method called altmetric analysis. Methods: The data were obtained from the Altmetric Explorer database using the phrase “child abuse,” in 2021. After being ranked by altmetric attention score (AAS), descriptive statistics for all publications as well as detailed analyses for the first-100 publications were performed. Variables evaluated were AAS, dimensions-badge value, distribution of web sources, demographic/geographic-breakdown type distributions, main subject categories, and mesh terms. Kruskal Wallis test was used for AAS and dimensions-badge value comparisons while Spearman correlations and regression analysis were also performed. Analyses were performed by SPSS 23.0 (IBM SPSS, Inc., Chicago, IL, USA) and p<0.05 was considered statistically significant. Results: Publications about child abuse were shared extensively on social media, mostly on Twitter. In terms of the main subject, sexual abuse was the trending topic, followed by physical abuse and maltreatment. Psychology, studies in human society, health sciences, and law/legal issues were the four main science categories about the subject. The United States was the major disseminator of publications while Child Abuse and Neglect was the most productive journal. There was a weak but significant (p<0.05) positive correlation between AAS and dimensions-badge values. Conclusion: Child abuse is a multidimensional subject in social media. As the number of publications increases, the possibility of articles to be shared on different social media platforms also increases. The majority of the top-100 publications are the ones emphasizing the importance of child abuse in terms of the prevalence, individual/social burden, and negative consequences.


Introduction
Child maltreatment or child abuse is a worldwide problem that may lead to serious and lifelong negative effects. All forms of abuse and neglect against minors under the age of 18 constitute child maltreatment. To be more precise, any form of physical and/or biological abuse, sexual exploitation, negligence, apathy that has potential ill-effect on the child`s health, life, and development and applied by who is in a relationship of trust, dependency, or power with a child is considered in the context of maltreatment. Not taking action in a situation that may harm a child is also considered maltreatment. Studies show that about three out of four children between 2 and 4 years of age have been subjected to psychological violence and/or physical punishment regularly by their parents or caretakers [1].
Child neglect and abuse can be classified according to their fatal and non-fatal consequences [2] or depending on whether the treatment of the child is physical, sexual, or emotional [3]. The view is that psychological abuse, also called emotional abuse, is the most common type of abuse and is gradually increasing. On the other hand, attitudes and behaviors that may cause emotional harm to the child in the relationship with the caregiver are considered psychological abuse. This form of abuse is an area where awareness is insufficient compared to its frequency, less known than sexual and physical abuse, and information on its causes, consequences, prevention, and treatment is limited [4]. All kinds of sexual contact, exhibitionism, or sexual harassment against a person who cannot give consent or where there is no real consent, is called sexual violence. The use of the term abuse in this context refers to the disproportionality and severe unjustness of an act against a child in terms of power relations, lack of real consent, vulnerability, and inequality of the child [5,6]. Since the definition of sexual abuse differs according to the culture and laws, its prevalence also varies according to the accepted definition [1]. In a study investigating lifetime sexual abuse exposure of adolescents based on self-report, it was reported that 11.2% of women and 1.9% of men were exposed to sexual abuse by an adult. It has been found that the frequency of sexual abuse increases with age in adolescence [7]. Physical abuse is defined as an act that results in physical harm by a person who is responsible for the child or who is in a relationship of power or trust. Not doing anything for a potentially harmful situation is also included in the scope of physical abuse [8]. It is known that the frequency of physical abuse against children varies in a wide range according to the culture in which it is researched. In a meta-analysis in which data from 168 studies were analyzed, the combined prevalence of physical abuse towards children was reported as 17.7% [9]. Apart from these, any action that results in harm to the child, such as child labor, prostitution, and that takes place within the framework of power disproportion is considered child abuse [8]. Neglect is the failure of the caregiver to use the necessary and accessible opportunities for the child's development. Neglect can occur in areas such as health, education, emotional development, nutrition, and shelter; it may also adversely affect the child's health, physical, mental, spiritual, moral, or social development. In other words, neglect is the failure to supervise children properly and to protect them from harm as much as possible [8]. The prevalence of child neglect was reported as 16.3% for physical neglect and 18.4% for emotional neglect; therefore it stands out as a common and important problem [10].
Child abuse had been discussed in academia for long years and evaluated by citation-based metrics, namely bibliometric studies, quite a lot [11]. However, in this scientific study with the theme of child abuse based on social attention, we used a relatively new alternative analysis method called "article-level metrics" or "altmetrics" [12] and we try to exhibit the complementary social media aspect of the topic. Contrary to citation-based metrics (such as journal impact factor and h-index) which reflect the citing dynamics of articles or books, this new method additionally detects, lists, and evaluates articles most discussed in electronic literature, social media accounts, blogs, podcasts, and news media [13,14]. The score called "Altmetric Attention Score" (AAS) in altmetrics means a publication rises as more people mention it. It simply shows where citations originate from; namely, they originate from public policy documents, mainstream media, Wikipedia, blogs, citations (including Web of Science), social media (Twitter, LinkedIn, Google+, Sina Weibo, and Pinterest) or Multimedia and other online platforms (YouTube, Reddit, etc.) [15]. Eventually, this article gives insight into what is popular in social media about child abuse and explains the dissemination dynamics of the related articles.

Data collection
In this scientific research, AAS data in Altmetric Explorer since 2010 were analyzed. The data were obtained from the Altmetric Explorer (available from https://www.altmetric.com) database using the phrase "child abuse" (Date of access: January 5, 2021). Then, all publications on child abuse were ordered from highest to lowest AAS, to reflect the real rating of articles. Each of the writers (pediatric surgeon, pediatrician, child, and adult psychiatrists, public health and emergency medicine professionals) peer-reviewed all publications and select the topic-related articles with consensus. Analysis of the main subject categories and mesh terms enabled writers to avoid keyword-related misses. Besides, among these, the main ideas and Mesh Terms of the top 100 articles were analyzed.

Statistical analysis
Descriptive statistics (mean ± standard deviation for numerical variables, min-max, and number and percentile values for categorical variables) of all identified publications were performed in this study. Additionally, the top-100 publications with the highest AAS were evaluated with further analyses. Associations between altmetric parameters, namely AAS (an automatically calculated weighted count of all of the attention a research output has received in social media) and dimensions badge value (calculated by interactive visualizations that showcase the citation data origins for individual publications) were identified. The monthly comparisons of AAS and dimensions badge values were made with the Kruskal Wallis test and Dunn test used for post hoc tests. Spearman correlation coefficients were calculated to detect the linear relationship between numerical variables. The correlation coefficients were interpreted as follows: less than 0.4, weak; 0.4-0.6, moderate; 0.6-0.8, strong and 0.81-1.00 high strong relationship [16]. Beta coefficients were estimated by univariate linear regression analysis.

General analysis results for all publications
We discovered 9,534 publications using the phrase "child abuse" in our Altmetric Explorer search. Among all, 9,411 papers were analyzed after excluding the unrelated topics. The average Altmetric score for publications was 7.32± 26.32. (851-0) whereas the average dimensions badge score of the publications was 30.04± 79.53 (0-2431). Authors, titles, AAS scores, dimensions-badge values, and the rankings of the top-100 publications can be seen in Table 1.

Rank Title Journal/Collection
Title Altmetric Score Dimensions

Mentions, journals, and outputs
When document types were analyzed, the majority of the publications disseminated in social media about child abuse were articles (n=8,365), followed by chapters (n=645), books (n=327), news (n=72), and clinical trial data (n=2). When top-100 publications about child abuse were analyzed based on their mentions, the most often mentioned social media platforms were Twitter, Policy, News, and Facebook, respectively. Demographics of mentions were summarized in Table 2. Web of Science categories of child abuse publications disseminated in social media is given in Figure 1. Mainly four categories were detected: psychology and cognitive sciences followed by studies in human society (social work, criminology, and policy), health and health sciences (public health and clinical sciences), and law and legal issues.    Table 3. The distributions of the number of mentions in each social media platform by journals (for the top five journals) were summarized in Table 4. In each social media platform, 24.6%-39.5% of the disseminations were attributed to the journal named Child Abuse & Neglect. Journals with a number of publications over 12 are summarized in Figure 2.

Number of posts by countries
The worldwide distribution of posts by country is given in Figure 3. Apart from unknown origins, the top-3 countries producing the utmost dissemination were the United States, the United Kingdom, and Australia.  Table 1.
Analysis of the top-100 list main subject category reveals that the majority of articles were related to sexual abuse (n=52), maltreatment (n=14), and physical abuse (n=14) (Figure 4). Mesh terms of the top-100 articles are summarized in Figure 5.

Correlation and regression analysis of the Altmetric score and dimensions-badge values for the T100 list
Scatter plots of the relationship between dimensions and altmetric scores were summarized in Figure 6.
There was a weak positive correlation between altmetric scores and dimensions-badge values (r=0.161; p=0.001) ( Figure 6). Univariate linear regression analysis revealed that 0.26% of the variation in altmetric was explained by dimensions ( Table 5). One unit increase in dimensions resulted in a 1.23 unit increase in altmetrics. Regression model to estimate altmetric as follows: Y Altmetric=1.23*X Dimensions.

Discussion
With its different forms of occurrences, child abuse still stands before us as a multifaceted social problem and it is understood that it has been on the agenda in social media for all years since the beginning of the production of altmetric data.
A weak positive correlation between AAS (the weighted count of all of the attention a research output has received) and dimensions-badge (the summary of the web origin of citations about the publication in concern) reminds that the two altmetric parameters are related to each other. This means that the shares of the publications and the prevalence of these shares in different social media account types change simultaneously.
Child abuse concerns a wide range of disciplines in the context of social media. It is understood that there is a lot of sharing in the field of psychology and studies in human society (sociology, politics and administration, social work, and criminology) followed by health sciences (especially public health, clinical sciences, pediatrics, nursing, neurosciences) and law [17,18]. Some very diverse branches also made publications about child abuse such as education, language, communication and culture, economics, philosophy, and religious studies, historical studies, genetics, information and computing sciences, commerce, management, tourism, business, marketing, chemical sciences, journalism and professional writing, biomedical engineering, built environment and design.
Publications are shared extensively on social media, mostly on Twitter. After Twitter, the most disseminated social media area has been policy documents. This is an indication that the official and judicial dimension of the issue constitutes the agenda. Then news occupies an important place, that is, there are publications with news quality, and they are shared widely. It is noteworthy that Facebook and blog posts for child abuse are relatively few. Therefore, the subject is a hot topic both in the scientific community, in official channels, and in social media news channels.
Although scientific disseminations about child abuse originate worldwide, scientifically productive and developed countries such as the United States, United Kingdom, Australia, Canada, Japan, Spain, France generated most of the dissemination. The fact that the issue is an important topic in the United States and the United Kingdom may increase the potential for such research to be shared by these countries [19]. The large body of research on child abuse in these countries may also reflect the great anxiety that the Western world has devoted to it. Higher awareness of children's rights in these countries may also contribute to this situation [19,20]. However, some reports showed that the trend of child abuse was not a true increase in prevalence but due to the changes in legislation [21,22]. In low and middle-income countries, where child abuse is seen as taboo and sensitive, such publications are less common [23]. In a sample of nine countries, according to a research article, the use of corporal punishment for children was lowest by Swedish parents and highest by Kenyan parents [24]. It can also be considered that a subject such as child abuse remains in the background, as low and middle-income countries give more importance to the studies to meet the basic needs of the society.
We see that the publications in the Child Abuse & Neglect journal occupy the most agenda on all social media platforms. It is seen that the Child Abuse & Neglect journal has published articles in this field for a long time (since 1977) and has a high impact factor (reported as 3.9 for 2019) compared to other journals in the ranking. In addition, a high number of annual total articles since it is published monthly and listing of this journal in many indexes can explain the fact that the articles in the journal reach large audiences and take more space in social media.
When the content of the most-disseminated top-100 publications was evaluated in terms of the main subject, sexual abuse was the trending topic ( Figure 4). This is followed by physical abuse and maltreatment.
Since the legal consequences of sexual abuse are more pronounced and severe; also, it is more documented due to legal processes, it may become a current issue. It does not seem very possible to explain this only from a medicolegal perspective. Even if the consequences of sexual abuse are not very obvious in the early periods in some cases, more apparent problems may arise during the adolescence period when sexual development accelerates or when sexual activity begins. Finally, the most unacceptable form of child maltreatment may be to approach a child sexually. For example, in some cultures, physical violence is considered more normal (There are some proverbs in Turkish culture, for example, those who do not beat their daughter will beat their knees). Since ancient times, we see that the behaviors of daily life, which we today accept as child abuse, were the natural cultural elements of life both in the world and in the Anatolian lands during and before the Ottoman Empire [25]. However, while there may be families who find it normal to physically punish their children for disciplinary purposes, we do not come across a culture that considers sexual behavior towards a child normal [26]. Nevertheless, looking at the marriage statistics in Turkey, 17,058 girls aged 16-17 were married in 2019, and 13,014 girls were married in a civil marriage in 2020 [27]. While marriages before the age of 16 are not reflected in official figures. Again, according to official statistical figures, 8,271 girls under the age of 17 gave birth in 2020 and 10,045 girls in 2019 [28]. These figures can be considered striking indicators of the intertwining of sexual abuse with culture. Therefore, sexual abuse may be becoming more noticeable.
On the other hand, it has been seen that the issue of emotional abuse, which is known to occur a lot, is rarely talked about. Although it is known that emotional neglect and abuse are very common, there are difficulties in documenting them. It is seen that the effect on the psychological and mental health of the victim has also been less studied. From this point of view, it can be thought that emotional abuse and neglect of the child are neglected also scientifically [4]. It can be accepted plausible that a topic containing little data may become less apparent.
Again, it has been noticed that "awareness of child abuse," which is considered as an important step in the prevention of abuse, is relatively less discussed in social media. Child neglect and abuse is a common condition that is likely to be found in many people's life histories, and increased awareness can lead to the recollection of individual traumas and stress. From this point of view, inadequate handling of awareness of abuse may be an avoidance mechanism. When considered from another point of view, talking less about awareness can also be evaluated as an effort to keep away from situations that are perceived as bad and dangerous. Increasing awareness of child neglect and abuse reminds us that this is a very common and frequent reality. However, some of the ways to cope with highly emotionally charged situations are to ignore them or to keep the dangerous situation out and away. The underappreciation of awareness may be serving this ignorance [29]. Another reason for the low awareness of abuse may be that the perpetrators are from the family and close circles. In such cases, families avoid this confrontation for reasons such as not experiencing tension in the family, avoiding gossip in the neighborhood, or the emotional shock of the event. According to the results of the Research on Domestic Violence Against Women in Turkey; 9% of women have been sexually abused before the age of 15. While 29% of the perpetrators are male relatives, 15% are reported as people from close circles such as neighbors or grocers [30].
In the evaluation made based on mesh terms, the publication could be evaluated beyond the mere main idea, with its much different dimensions. Evaluation reveals that the most used mesh term is "humans." This is followed by 'child'. In addition, child abuse was also examined in terms of gender, and focused more on the female. The developmental stage of the victim (preschool, adolescent, middle-aged, adult) has been important when dealing with child abuse. When child abuse is a legal issue, it is also paired with terms such as punishment, sex offenses, and crime victims.
The majority of the top-100 publications are the ones emphasizing the importance of child abuse in terms of the prevalence, individual and social burden, and negative consequences, and reflecting general information about the subject. In addition, there are publications that attracts attention due to their striking results ( Table 1; #2, #3, #11, #13, #15, #58, #66, #87). There are reports about the ways that lead to child abuse or the underlying causes of this event, such as the intergenerational transmission of the trauma or the possibility of yesterday's victim being the perpetrator of today ( Table 1; #18, #20). An article argued that perpetrators are mostly men, contradicting our preconceived notions ( Table 1; #51). Also, a 15-year prospective followup study that examines some factors possibly protective for child abuse (Table 1; #88), as well as a study that addresses a current issue such as child neglect and abuse during the COVID-19 pandemic ( Table 1; #36) were popular.

Limitations
Although altmetric analysis enables a quantitative look at social media accounts in terms of scientific article disseminations, this method has some limitations. The infrastructure of Altmetric Explorer enables a general look at the investigated subject in both qualitative and quantitative ways and gives an opportunity to investigate every single article individually, but it is not always possible to evaluate a huge number of publications in such a detailed way, usually, top-50 or top-100 evaluated in a detailed way (as in this study). Also, the main dissemination route for Altmetric Explorer is Twitter, thus different platforms might have been less represented in this study.

Conclusions
Child abuse is a common type of trauma all over the world. It concerns many different scientific disciplines, from health to law, from psychology to sociology, whose effects can last a lifetime, cause negative consequences and, create a social burden. Scientific publications on child abuse are hot-topics in the scientific community, official media channels, and social media news channels. It is understood that Twitter is especially effective in spreading the issue. Child abuse is discussed in social media with many different aspects, but especially with the dimension of sexual abuse. Efforts to prevent child abuse also particularly attract attention.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. University Ethical Committee issued approval 2021/57-10. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.